Balance
Impairment in balance is a major risk factor for falls and a balance assessment is recommended in the 2023 American Thoracic Society/European Respiratory Society Clinical Statement on Pulmonary Rehabilitation and in the WHO Package of Interventions for Rehabilitation for people with chronic obstructive pulmonary disease (COPD). In this section, outcome measures that have been applied in pulmonary rehabilitation programmes to assess balance and balance confidence are reported. Both rater-administered and self-reported measures are included. In most instances, data is reported on individuals with COPD because balance has limited assessment in other chronic lung disease populations attending pulmonary rehabilitation.
The following outcome measures on balance are described.
- Activity-Specific Balance Confidence (ABC) Scale
- Balance Evaluation Test-BESTest
- Berg Balance Scale-BBS
- Brief-BESTest
- Mini-BESTest
- Performance Oriented Mobility Assessment (Tinetti)
- Single Leg Stance-SLS
- Timed Up and Go Test-TUG
We thank the following who collated this material: Professor Samantha L Harrison, Dr Kirsti J Loughran and Chibuzo Achugwo (School of Health and Life Sciences, Teesside University, Middlesbrough, UK), A/Professor Marla Beauchamp (McMaster University, Toronto, Canada), Professor Suzanne Lareau (University of Colorado, Denver, US) and Professor Clarice Tang (Victoria University, Melbourne, Australia).
Listing of Balance Outcomes for PRA
| Developer | Edited by | Date Finalized | |
|---|---|---|---|
| 1. Activity-Specific Balance Confidence (ABC) Scale | Sam HarrisonKirsti Loughran | C Tang | 2-19-24 |
| 2. Balance Evaluation Test-BESTest | SLH, MKL, Chibuzo Achugwo | CT | 2-19-24 |
| 3. Berg Balance Scale-BBS | SLH, MKL | CT | 2-19-24 |
| 4. Brief-BESTest | CT | SL | 2-21-24 |
| 5. Mini-BESTest | Suzanne Lareau | CT | 2-19-24 |
| 6. Performance Oriented Mobility Assessment (Tinetti) | SLH, MKL | CT | 2-19-24 |
| 7. Single Leg Stance-SLS | SLH, MKL | CT | 2-19-24 |
| 8. Timed Up and Go Test-TUG | SLH, MKL | CT | 2-19-24 |
Activity-Specific Balance Confidence (ABC) Scale
| Description | |
|---|---|
| Name of Instrument | Activity-Specific Balance Confidence Scale1 |
| Abbreviation/Alternate Name | ABC |
| Description: | A measure of an individual’s confidence that they will not lose their balance or become unsteady during a series of ambulatory activities. |
| Developer | Anita M. Meyers |
| amyers@uwaterloo.ca | |
| Cost | Print version of scale may be reproduced for student training, research and clinical practice in which the scale is used to assess <1000 patients/annually. |
| License required | Permission must be obtained by the researcher or institution. Contact: amyers@uwaterloo.ca |
| Self-or rater-administered | Face-to-face interview (recommended) or self-administered |
| Time to complete | 5 - 10 minutes |
| Number of items | 16 |
| Domains & categories | Not applicable |
| Name of domains/categories | Not applicable |
| Scaling of items | Likert scale from 0% (not confident at all) to 100% (completely confident) in increments of 10%. |
| Scoring | The average score obtained across 16 items (0-100%). Score of ≤ 58% indicate fallers in COPD.2 |
| Test-retest/reproducibility | Test-retest reliability in COPD (r= >0.90)3 |
| Validity | Construct and concurrent in COPD2,4,Criterion predictive for falls in COPD5Good correlation with BBS, BESTest and 6MWT (r=0.54-0.56, p=0.001)2 |
| Responsiveness to PR | Unclear6,7 |
| MID | 19%8 |
| Languages | Available and validated in multiple languages e.g., Chinese (Cantonese)9, Urdu10 |
| References | 1. Powell LE, et al. J Gerontol A Biol Sci Med Sci. 1995; 50: M28-M34. 2. Alsubheen et al. Expert Rev Respir Med. 2022; 16:689-696. 3. Mkacher, W et al. J Cardiopulm Rehabil Prev. 2017; 37:223-22. 4. Roig, M et al. Physiother Can. 2011; 63: 423-431. 5. Beauchamp, M et al. Resp Med. 2009; 103:1885-1891. 6. Mkacher, W et al. J Cardiopulm Rehabil Prev. 2015; 35:207-213. 7. Beauchamp, M et al. Chest. 2013; 144;1803-1810. 8. Beauchamp, M et al. Chest. 2016; 149:696-703. 9. Mak, M et al. Arch Phys Med Rehabil.2007; 88; 496-504. 10. Fatima, N et al. Pakistan J Med Health Sciences. 2021; 15; 3505-3508. |
| Date this page was updated | February 2024 |
Balance Evaluation Systems Test
| Description | |
| Name of Instrument | Balance Evaluation Systems Test1 |
| Abbreviation/Alternate Name | BESTest. 3 |
| Description: | A clinical balance assessment tool which assesses impairments across six sub-systems of postural control. |
| Developer | Fay B Horak |
| horakf@ohsu.edu | |
| Cost | No charge for clinical and research purposesat: https://www.bestest.us/test_copies/ |
| License required | None |
| Self-or rater-administered | Rater-administered |
| Time to complete | 20-30 minutes (45 minutes for COPD) |
| Number of items | 36 |
| Materials needed | 1. Stopwatch 2. Measuring tape mounted on wall for Functional Reach test. 3. Approximately 60 cm x 60 cm (2 X 2 ft) block of 4-inch, medium-density, Tempur® foam 4. 10-degree incline ramp (at least 2 x 2 ft) to stand on 5. Stair step, 15 cm (6 inches) in height for alternate stair tap. 6. Two stacked shoe boxes for obstacle during gait. 7. 2.5 Kg (5-lb) free weight for rapid arm raise 8. Firm chair with arms with 3 meters in front marked with tape for Timed Get Up and Go test. 9. Masking tape to mark 3 m and 6 m lengths on the floor for Timed Get Up and Go. |
| Domains & categories | 6 |
| Name of domains/categories | 1. Biomechanical constraints 2. Stability limits/verticality 3. Anticipatory postural adjustment 4. Postural responses 5. Sensory orientation 6. Stability in gait |
| Scaling of items | Ordinal scale: 0 (severe balance impairment) to 3 (no balance impairment). |
| Scoring | Percentage of total points (maximum 108 points).Domain scores can be generated separately as a percentage of the total score.Cut off scores to identify fallers in people with COPD = 76.92 |
| Test-retest/reproducibility | ICC’s in COPD, inter-rater reliability (95% CI) 0.94 (.88, .97) and intra-rater 0.52 (0.19, .74)2 |
| Validity | Construct2,3,4,5 |
| Responsiveness to PR | Yes6,7 |
| MCID | 13-17 points8 |
| Languages | Available in multiple languages from website |
| References | 1. Horak FB et al. Phys Ther, 2009; 89: 484-98. 2. Jacome, C et al. Phys Ther. 2016; 96:1807-1815. 3. Franchignoni et al, J Rehabil Med, 2010; 42:323-313. 4. Beauchamp, M et al. Resp Med. 2009; 103:1885-1891. 5. Beauchamp, M et al. Chest. 2012; 141:1496-1503. 6. Beauchamp, M et al. Chest. 2013; 144:1803-1810. 7. Beauchamp, M et al. Arch Phys Med Rehabil. 2010; 91:1460-1465. 8. Beauchamp, M et al. Chest. 2016; 149:696-703. |
| Date this page was updated | February 2024 |
Berg Balance Scale (BBS)
| Description | |
| Name of Instrument | Berg Balance Scale1 |
| Abbreviation/Alternate Name | BBS |
| Description: | A comprehensive measure of a persons’ balance abilities. |
| Developer | Katherine Berg |
| Katherine.berg@utoronto.ca | |
| Cost | No charge at https://www.sralab.org/rehabilitation-measures/berg-balance-scale |
| License required | None |
| Self-or rater-administered | Rater-administered |
| Time to complete | 15-20 minutes (30 minutes for COPD) |
| Number of items | 14 specific movements |
| Materials needed | 1. Ruler or measuring tape 2. Standard height chair(s) (18-20 inches) with/without armrests 3. Step or stool (height 7.75-9inches) 4. An object that can be picked up (e.g., slipper/shoe) 5. Stopwatch or wristwatch. |
| Domains & categories (#) | Not applicable |
| Name of domains/categories | Not applicable |
| Scaling of items | Likert scale from 4 (maximum independence and stability) to 0 (high dependence and instability) |
| Scoring | Item scores are summed (0-56 points).Cut off score to identify fallers COPD = 52.52 |
| Test-retest/reproducibility | Test-retest in COPD (r=>0.90).3Inter [ICC (95%CI)= 0.94 (0.88-0.97)] and intra-rater reliability [ICC (95%CI)= 0.52 (0.19-0,74)] in COPD. 2 |
| Validity | Construct and concurrent in COPD 2,4,5Correlation (r=0.75) with ABC scale 2 |
| Responsiveness to PR | Yes 6,7 |
| MID | 5-7points8 |
| Languages | Portuguese, Italian, Greek, Turkish, Norwegian & Hindi |
| References | 1. Berg, K et al. Physiother Can. 1989; 41:304-311. 2. Jacome, C et al. Phys Ther. 2016; 96:1807-1815. 3. Mkacher, W et al. J Cardiopulm Rehabil Prev. 2017; 37:223-22. 4. Beauchamp, M et al. Resp Med. 2009; 103:1885-1891. 5. Beauchamp, M et al. Chest. 2012; 141:1496-1503. 6. Beauchamp, M et al. Chest. 2013; 144:1803-1810. 7. Mkacher, W et al. J Cardiopulm Rehabil Prev. 2015; 35:207-213. 8. Beauchamp, M et al. Chest. 2016; 149:696-703. |
| Date this page was updated | February 2024 |
Brief-Balance Evaluation Systems
| Description | |
| Name of Questionnaire | Brief-Balance Evaluation Systems Test1 |
| Abbreviation/Alternate Name | Brief-BESTest |
| Description: | A modification of the BESTest2 clinical balance assessment tool which evaluates more aspects of balance than the BBS, including reactive balance and cognitive influence |
| Developer | Parminder K Padgett |
| Contact jjacobs@uvm.edu for permission to use tool | |
| Cost | No charge |
| License required | Contact jjacobs@uvm.edu for permission to use tool |
| Self-or rater-administered | Rater-administered |
| Time to complete | 10 minutes |
| Number of items | 6 |
| Materials Needed | 1. Approximately 60 cm x 60 cm (2 X 2 ft) block of 4-inch, medium-density, Tempur® foam 2. Stopwatch 3. Chair without arm rests or wheels 4. Measuring tape mounted on wall for Functional Reach test 5. Masking tape to mark 3m on the floor from chair. |
| Domains & categories (#) | 6 |
| Name of domains/ categories | 1. Anticipatory postural adjustment 2. Postural responses 3. Sensory orientation 4. Stability in gait 5. Biomechanical constraints: Hip strength 6. Stability limits/verticality: Reach forward |
| Scaling of items | “0” (unable to perform or severe balance impairment) to “3” (normal performance) |
| Scoring | Total points (Maximum 24 points). 2 items (anticipatory postural adjustment and reactive postural response) are completed on the left and right.Cut off scores to identify fallers in people with COPD=16.53 |
| Test-retest/reproducibility | Inter-rater ICC= 0.97 (0.94-0.99) and Intra-rater ICC= 0.82 (0.66-0.92)3 Cronbach α>0.824 |
| Validity | Construct3,4,5 |
| Responsiveness to PR | Yes6,7 Predicts falls in COPD4 |
| MID | 3 points in people with COPD following PR with balance training6 |
| Languages | Not available |
| References | 1. Padgett PK et al. Phys Ther. 2012;1197-1207. 2. Horak FB et al. Phys Ther. 2009; 89: 484-98. 3. Jacome C et al. Phys Ther. 2016; 96: 1807–1815. 4. Lo CWT et al. Arch Phys Med Rehabil. 2022; 103:155-175. 5. McLay R et al. Chron Respir Dis. 2020; 17:1-10. 6. Paixão C et al. ERJ. 2020;56:2935.7. O’Hoski S et al. Physiother Canada. 2022; 103:155-175. |
| Date this outcome was updated | February 2024 |
Mini-Balance Evaluation Systems
| Description | |
| Name of Questionnaire | Mini-Balance Evaluation Systems Test1 |
| Abbreviation/Alternate Name | Mini-BESTest |
| Description: | A modification of the BESTest2 clinical balance assessment tool evaluating four aspects of balance |
| Developer | Franco Franchignoni |
| http://www.bestest.us/test_copies/ | |
| Cost | No charge |
| License required | © 2005-2013 Oregon Health & Science University. All rights reserved. |
| Self-or rater-administered | Rater-administered |
| Time to complete | 15 minutes |
| Number of items | 14 |
| Materials Needed | 1. Approximately 60 cm x 60 cm (2 X 2 ft) block of 4-inch, medium-density, Tempur® foam 2. Stopwatch 3. Chair without arm rests or wheels 4. 10-degree incline ramp (at least 2 x 2 ft) to stand on 5. A box (9” height) 6. Masking tape to mark 3m on the floor from chair. |
| Domains & categories (#) | 4 |
| Name of domains/ categories | 1. Anticipatory postural adjustment 2. Postural responses 3. Sensory orientation 4. Stability in gait |
| Scaling of items | “0” (unable to perform or requiring help) to “2” (normal performance) |
| Scoring | Percentage of total points (maximum 28).Sub-system scores can be generated separately as a % of total score.Cut off scores to identify fallers in people with COPD=22.53 |
| Test-retest/reproducibility | Inter-rater ICC= 0.85 (0.71-0.93) and Intra-rater ICC= 0.88 (0.76-0.94)3 |
| Validity | Construct3,4 |
| Responsiveness to PR | Inconclusive in PR. Predicts falls in COPD5 |
| MID | 46 (Godi says 4 pt diff represents 14% change; Beauchamp says 13% in CRD 2018) |
| Languages | Available in multiple languages from website http://www.bestest.us/test_copies/ |
| References | 1. Franchignoni F et al. J Rehabil Med. 2010; 42:323-313. 2. Horak FB et al. Phys Ther. 2009; 89: 484-98. 3. Jacome C et al. Phys Ther. 2016; 96: 1807–1815. 4. Morlino P et al. Gait Post 2017; 58: 352–357. 5. Pereira, A et al. J Cardiopulm Rehab & Prev. 2019; 39: 391-396. 6. Godi M et al. Phys Ther. 2013; 93:158–167. |
| Date this page was updated | January 2024 |
Performance Oriented Mobility Assessment (Tinetti)
| Description | |
| Name of Instrument | Performance Oriented Mobility Assessment1 |
| Abbreviation/Alternate Name | POMA or Tinetti’s mobility test (TMT) |
| Description: | Comprehensive measure of a persons’ balance and gait ability during seated and standing static balance tasks and during gait. Should be performed on those ≥65 yrs and those with sarcopenia, frailty syndrome, dementia and others previously identified risk factors for fall. |
| Developer | Mary Tinetti |
| mary.tinetti@yale.edu | |
| Cost | No charge at:https://www.thecalculator.co/health/Tinetti-Balance-Test-Calculator-1031.html |
| License required | No |
| Self-or rater-administered | Rater-administered |
| Time to complete | 10-15 minutes |
| Number of items | 16 |
| Materials needed for ABC | Scoring sheet and pen Firm chair without armrestsStopwatch15 ft (5m) walkway |
| Domains & categories | 2 |
| Name of domains/categories | Balance Gait |
| Scaling of items | 3-point ordinal scale (0-2) where higher scores indicate greater independence. |
| Scoring | Items summed (max score 28 points). Domains can be scored separately balance (max score 16) and gait (max score 12).High risk= ≤ 18 points; Moderate =19-23; Low= ≥ 24 risk for falls. |
| Test-retest/reproducibility | Test-retest in COPD r=>0.902 |
| Validity | Construct3 |
| Responsive to PR | Yes4 |
| MID | Unknown |
| Languages | Available in multiple languages |
| References | Tinetti ME et al. Am J Med. 1986; 80: 429-434.Mkacher W et al. J Cardiopulm Rehabil Prev. 2017; 37:223-228.Rocco CC et al. Clinics (Sao Paulo). 2011; 125-129Mkacher W et al. J Cardiopulm Rehabil Prev. 2015; 35:207-213. |
| Date this outcome was updated | February 2024 |
Single Leg stance (SLS)
| Description | |
| Name of Instrument | Single Leg Stance1,2 |
| Abbreviation/Alternate Name | SLS or One-Legged Stance Test (OLST) or Unipedal Stance Test (UPST) |
| Description: | A simple balance screening test which assesses static postural control while standing on one leg. |
| Developer | Roberta Newton |
| Not available | |
| Cost | No charge |
| License required | Not applicable |
| Self-or rater-administered | Rater-administered |
| Time to complete | 1 minute |
| Number of items | Not applicable |
| Materials needed | 1. Scoring sheet and pen 2. Stopwatch |
| Domains & categories | Not applicable |
| Name of domains/categories | Not applicable |
| Scaling of items | Time (in seconds) required to complete the task |
| Scoring | Time in seconds (max 60)Cut-off to identify fallers in COPD = < 6.8 seconds3 |
| Test-retest/reproducibility | Test-retest in COPD r= >0.904 |
| Validity | Concurrent, convergent3 |
| Responsiveness to PR | Yes5 |
| MID | Unknown |
| Languages | Given simplicity of instructions, the SLS can be administered in different languages with informal translation |
| References | 1. Newton R. Brain Inj. 1989; 3:335-343. 2. Springer et al. J of Geriatr Phys Ther. 2007; 30:8-15. 3. McLay R et al. Chron Resp Di. 2020; 17:1-10. 4. Mkacher W et al. J Cardiopulm Rehabil Prev. 2017; 37:223-22. 5. Mkacher W et al. J Cardiopulm Rehabil Prev. 2015; 35:207-213. |
| Date this page was updated | February 2024 |
Timed Up and Go test (TUG)
| Description | |
| Name of Instrument | Timed up and go test1 |
| Abbreviation/Alternate Name | TUG |
| Description: | A balance screening test assessing mobility, balance and locomotor performance. |
| Developer | Mathias1 (original) and Podsiadlo2 (modified version) |
| Not available | |
| Cost | No charge |
| License required | Not applicable |
| Self-or rater-administered | Rater-administered |
| Time to complete | 1-2 minutes |
| Number of items | N/A |
| Materials needed | 1. Scoring sheet and pen 2. One chair with armrests 3. Stopwatch 4. Measuring tape |
| Domains & categories | Not applicable |
| Name of domains/categories | Not applicable |
| Scaling of items | Time (in seconds) required to complete the task |
| Scoring | Time in secondsCut off to identify risk of falls in COPD= >12 seconds3 |
| Test-retest/reproducibility | Test-retest in COPD r=>0.904Inter and intra-rater reliability in people with COPD >0.902,5 and ILD.11 Internal consistency α=0.962 |
| Validity | Construct3,6,7,8 TUG and 6MWT r=-0.74, p<0.001 in COPD3 and -0.62 to-0.69, p<.05 in ILD.11 |
| Responsiveness to PR | Yes7,9,10 |
| MID | 0.9-1.4 seconds7 after PR |
| Languages | Given the simplicity of the instructions the TUG can be administered in different languages with informal translation |
| References | 1. Mathias S. et al Phys Ther. 1986; 67:387-389. 2. Podsiadlo D et al. J Am Geriatr Soc. 1991; 39: 142-148. 3. Al Haddad MA. J Cardiopulm Rehabil. 2016; 36:49-55. 4. Mkacher W et al. J Cardiopulm Rehabil Prev. 2017; 37:223-22. 5. Marques et al. COPD. 2016;13:279-287. 6. Beauchamp M et al. Resp Med. 2009; 103:1885-1891. 7. Mesquita et al. Chron Resp Dis. 2016; 13:344-352. 8. Crisan et al. PLoS One. 2015; 10 e0120573. 9. Beauchamp et al Arch Phys Med Rehab 2010; 91:1460-1465. 10. Mkacher, W et al. J Cardiopulm Rehabil Prev. 2015; 35:207-213. 11. Zamboti CL et al. Respir Med. 2021; 184:106413. |
| Date this page was updated | February 2024 |
